Gloucestershire Royal Hospital
Requires improvement

Reports

Inspection carried out on 24-27/01/2017, 06/02/2017

During a routine inspection

We carried out an announced inspection 24-27 January 2017 and an unannounced inspection at Gloucestershire Royal on 6 February 2017. This was a focused inspection to follow-up on concerns from a previous inspection. As such, not all domains were inspected in all core services.

The inspection team inspected the following seven core services at Gloucestershire Royal Hospital:

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

We did not inspect the critical care services (previously rated outstanding).

As we did not inspect all services we did not rate Gloucestershire Royal Hospital at this inspection.

Safe

We rated the safe domain as requires improvement in urgent and emergency services, medicine, surgery, maternity and gynaecology and also outpatients and diagnostic imaging. We rated it as good in children’s and young peoples and end of life services.

We had concerns about patient safety, particularly when the emergency department was crowded. Lack of patient flow within the hospital and in the wider community created a bottle neck in the emergency department, creating pressures in terms of space and staff capacity. This in turn increased the risk that patients may not be promptly assessed, diagnosed and treated.

Crowding was compounded by an acute shortage of staff. There was an acute shortage of middle grade doctors and there were particular concerns raised by medical and nursing staff about medical cover at night. Consultants regularly worked longer hours to support their junior colleagues and there were concerns about whether this could be sustained. Analysis of demand patterns indicated that more senior decision-makers were required at night. The department was not fully staffed with nurses. There were a significant number of nurse vacancies and heavy reliance on bank and agency staff to fill gaps in the rota. The department was not consistently staffed to planned levels, and when the department was crowded staff felt vulnerable because planned safe staff to patient ratios could not be maintained.

There was no senior (band seven) nurse employed to manage each shift as recommended by the National Institute for Health and Care Excellence (NICE).

Support staff functions were not adequately resourced. Healthcare assistants performed housekeeping duties, doctors, nurses and managers moved patients, and the nurse coordinator was frequently occupied with administrative duties.

Crowding in the emergency department meant that ambulance crews were frequently delayed in handing over their patients.

Patients were not always assessed quickly on their arrival in the emergency department. Initial assessment (triage) often consisted of a verbal handover from ambulance staff to the nurse coordinator without a face to face assessment of the patient.

Record keeping was generally poor and we could not be assured that patients received prompt and appropriate assessment, care and treatment. In particular, we were concerned about the recording of observations and the calculation of early warning scores. Patient observations were not always carried out consistently or early enough and early warning scores were not consistently calculated.

The mental health assessment room did not comply with safety standards recommended by the Royal College of Psychiatrists.

Within the medical service, not all specialties held regular and structured mortality and morbidity meetings to ensure learning could be identified and shared.

Staff did not always follow infection control procedures when entering wards and ensuring the cleanliness of equipment such as commodes.

Wards did not display evidence of when areas such as toilets were last cleaned and we did not see environmental audit result displayed on the wards we visited.

Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).

The fabric of the building did not always ensure efficient cleaning could be carried out.

Daily checking of equipment such as resuscitation equipment was not carried out in all areas in line with the trust’s policy.

Medicines were not always managed correctly. Fridge temperatures were not monitored or actions taken where these fell out of normal range. There were a number of out of date patient group directives (PGD’s) in use in maternity services.

Records were not stored safely to ensure patient confidentiality was maintained at all times.

Staff did not always assess risks to patients and follow up with mitigating care interventions.

Nursing staffing levels were below establishment and wards, departments and operating theatres relied on bank and agency to cover shifts every day.

The trust did not use a recognised tool to assess the acuity of patients daily to ensure safe staffing levels were in place on each shift and particularly at night.

The number of surgical site infection rates for replacement hips and knees and spinal surgery had increased since our last inspection.

Mandatory training for all staff was not meeting the trust’s target.

The day unit was being used as an inpatient ward but domestic cover had not been set up for weekends to provide environmental cleaning or drinks to patients.

There was no cleaning carried out over the weekend in diagnostic imaging, and some outpatient treatment rooms and waiting areas were visibly dirty.

Staff were finding it difficult to trace patient notes since the introduction of a new computer system, and there was not a reliable system to track the numbers of temporary notes being used since its implementation. There were also some ongoing issues with allocation of baby NHS numbers and records migrating to the new system.

Some staff were unsure of their responsibilities in a resuscitation situation, and staff in ophthalmology did not know where to locate their nearest defibrillator.

In some areas, a systematic check of emergency resuscitation trolleys was not documented as having being carried out on a daily basis. There were no up to date Resuscitation Council (UK) guidelines available on the resuscitation trolleys. Intravenous fluids on the emergency resuscitation trolleys were not stored securely to ensure they were tamper evident.

Community midwives could not always print out clinical notes from the electronic system to go into women’s handheld notes. They also reported poor mobile phone coverage which meant there was sometimes a delay in getting messages.

Junior doctors in obstetrics did not attend skills drills training when they started at the trust though they did carry an emergency bleep and co0uld be the first to arrive in the delivery.

There were often long waiting times in the maternity triage area. Women were not seen within 15 minutes of attending the unit.

Consultant presence, on labour suite, was below the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007) guidance.

Not all outpatient waiting areas in the hospital had specific children’s areas. Areas that were not solely for children’s use in other parts of the hospital had waiting areas that were shared with adults.

However:

Staff understood their responsibilities to raise concerns and report incidents using the electronic reporting system. There was a culture of shared learning from incidents.

Staff spoke confidently about the duty of candour and gave examples of where it had been applied. Relevant staff had received training.

Most areas we visited were visibly clean and tidy. Staff were seen adhering to the trusts infection control policies including ‘bare below the elbows”.

There was a robust security system in place within the maternity unit, including locked doors, entry systems a baby security tagging system and CCTV.

There were systems in place for recognising and reporting safeguarding concerns. Staff were confident to raise any matters of concern and escalate them as appropriate.

There was good access to mandatory training within the maternity service, including skills drills training day and a one-day maternity update.

The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.

The endoscopy unit had safe processes in place to ensure staff decontaminated and sterilised equipment in line with best practice.

Within the emergency department, there were hourly board rounds undertaken by senior clinicians in the department. This provided an overview of the department’s activity and provided an opportunity to identify and communicate safety concerns to the site and trust management teams. Patient safety checklists had been introduced, which provided a series of time-sequenced prompts. There was a well-structured medical staff handover where patients’ management plans and any safety concerns were discussed.

Effective

We rated the effective domain as good in urgent and emergency services, surgery and end of life. We rated it as requires improvement in medical care, We did not inspect this domain in maternity and gynaecology or children’s and young people’s services

People’s care and treatment was mostly planned and delivered in line with current evidence-based guidance and standards.

There was a range of recognised protocols and pathways in place and compliance with pathways and standards was frequently monitored through participation in national audits. Performance in national audits was mostly in line with other trusts nationally. There was evidence that audit was used to improve performance.

Within the emergency department, nursing and medical staff received regular teaching and clinical supervision. Staff were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers.

Care was delivered in a coordinated and multidisciplinary way.

The trust had been identified as a ‘mortality outlier’ in to relation reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fractured hip. However, the actions had implemented had made improvements and these were ongoing at the time of our inspection.

Staff understood that end of life care could cover an extended period for example in the last year of life or patients and that patients benefited from early discussions and care planning.

End of life care was delivered with the principles of the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s

Within end of life care, medicines to relieve pain and other symptoms were available at all times. Wards had adequate supplies of syringe drivers (devices for delivering medicines continuously under the skin) and the medicines to be used with them.

However:

Pain was not always promptly assessed and managed within the emergency department and we could not be assured that patients’ nutrition and hydration needs were consistently assessed or met.

The trust was not meeting the standard which requires the percentage of patients re-attending (unplanned) the department within seven days to be less than 5%.

The new computer system was causing issues for staff resulting in 'work around' processes to prevent any risks to patients.

Staff appraisals were not meeting the trust targets in all areas.

Theatre utilisation figures were low however; the trust was looking at ways of improving this.

Explanations for the reason for the decision to withhold resuscitation attempts were not consistently clear. Records of resuscitation discussions with patients and their next of kin or of why decisions to withhold resuscitation attempts had been made were not always documented.

There was no organisational oversight of staff competency with regards to syringe driver training as records were not held centrally.

There was not a seven day face to face service provided by the in-patient and community end of life care team. The trust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals.

The learning needs of all staff delivering end of life care were not identified.

Caring

We rated the caring domain as good in all the services this domain was inspected (urgent and emergency services, medical care and end of life services).

All of the patients we spoke with during our inspection commented very positively about the care they received from staff. This was consistent with the results of patient satisfaction surveys, which were mostly positive.

Patients were treated with compassion and kindness. We saw staff providing reassurance when patients were anxious or confused.

Patients were treated with courtesy, dignity and respect. We observed staff greeting patients and their relatives and introducing themselves by name and role.

Patients and their families were involved as partners in their care. They told us they were kept well informed about their care and treatment. We heard doctors and nurses explaining care and treatment in a sensitive and unhurried manner.

Staff took the time to interact with people who received end of life care and those people close to them in a respectful and considerate manner.

Staff and volunteers who worked with the department for spiritual support, bereavement officers and the mortuary were aware of and respectful of cultural and religious differences in end of life care.

Emotional support for patients and relatives was available through the in-patient and community specialist palliative care team, through clinical psychology, social worker, ward-based nurse specialists and end of life champions, the chaplaincy team and bereavement services.

However:

The discharge lounge was a mixed sex unit and did not have curtains to screen individual chairs and provide privacy for patients in their pyjamas or when assistance was needed with personal care needs.

Whilst responses to the friends and family test was positive, response rates were frequently low.

Responsive

We rated the responsive domain as requires improvement in urgent and emergency services, medicine, surgery and outpatients and diagnostic imaging. We rated it as good in end of life services.

The emergency department was consistently failing to meet the standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the emergency department.

Patients frequently spent too long in the emergency department because they were waiting for an inpatient bed to become available. Lack of patient flow within the hospital and in the wider community created a bottleneck in the emergency department, causing crowding.

Crowding meant patients frequently queued in the corridor, where they were afforded little comfort or privacy. When the department became congested, relatives had to stand because there was insufficient seating.

Patients with mental health needs were not always promptly assessed or supported, particularly at night time when there was no mental health liaison service. Adolescents who had self-harmed did not receive a responsive service and were frequently inappropriately admitted while awaiting specialist assessment and support.

There was a lack of an appropriate welcoming space for patients with mental health needs.

The delivery of cardiology services did not meet the needs of the local population.

There were delays to discharges, which meant patient flow through the hospital was compromised.

There was a waiting list for patients requiring an endoscopic procedure.

The environment did not meet the needs of patients with dementia.

The trust reported 32 breaches of mixed sex accommodation in the period from January 2016 to October 2016 of which 11 were in the acute medical admissions unit.

The service was not always compliant with the accessible information standards and information leaflets were not readily available for patients for whom English was not their first language.

Due to pressure for beds and the demand on services, some patients had to use facilities and premises that were not always appropriate for inpatients. At times of high operational pressure patients were temporary admitted to endoscopy and medical day unit wards however, these were not identified as ‘escalation areas’ in the inpatient capacity protocol.

Elective operations were being cancelled due to the pressure on the beds within the trust and medical patients were being cared for on surgical wards to meet the demand.

Not all patients had their operations re-booked within the 28-day timescale.

Six patients had been waiting over 52 weeks for treatment, which is not acceptable.

The hospital was not meeting the 62 day target for cancer patients.

The diagnostic imaging department had a reporting backlog of 19,500 films and was not meeting its five day reporting target for accident and emergency x-rays.

A significant typing backlog was causing delays in sending out patient letters impacting on patient safety.

Implementation of new computer systems had impacted on waiting lists as some specialties could not see live waiting lists.

The trust was not meeting referral to treatment target in all specialities.

There were no designated beds for people receiving care at end of life. Side rooms were used when available but could not be guaranteed.

The percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not all known for all wards or hospital sites.

End of life complaints were not always handled promptly and in accordance with trust policy.

However:

The emergency and urgent care service had a number of admission avoidance initiatives in place to improve patient flow. These included the integrated discharge team who proactively identified and assessed appropriate patients who may be able to be supported in the community rather than admitted to the hospital.

We saw evidence that complaints were used to drive improvement.

The emergency department had recently developed a team known as the Gloucestershire elderly emergency care (GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patients in the emergency department and to identify areas where the experience of this patient group could be improved.

Multi-agency management plans had been developed for patients with mental health needs who were frequent attenders in the ED. These enabled staff to better support patients and had resulted in a reduction of both ED attendances and admissions to hospital.

The trust’s referral to treatment time (RTT) for admitted pathways for medical services has been better than the England overall performance.

The average length of stay was for non-elective patients were better than the England average.

Staff in theatres and recovery had guidance in place to help reduce the anxiety of patients living with dementia when they using their services.

Rapid access assessment clinics were provided in some specialities, and some clinics were performing airway assessments via skype.

The hospital had introduced a new waiting list validation process to discharge patient’s ongoing follow up care to community based services such as GPs.

The in-patient specialist palliative care team was available to ward staff to provide advice and training regarding communication and end of life care; this included communicating with patients and carers.

The trust was one of two sites in the country which had been developing a medical examiner role and improved death certification process project since 2008. Benefits included better support for relatives over the explanation and causes of death as well as ensuring better oversight of signing of death certificates

The specialist palliative care team responded promptly to referrals, usually within one working day.

Well-led

We rated well-led domain as requires improvement in medical care and good in urgent and emergency care and end of life care.

There was a strong, cohesive and well-informed leadership team within the emergency and urgent care service who were highly visible and respected. The service had a detailed improvement plan in place with clear milestones and accountability for actions.

The emergency department produced high quality information which analysed demand capacity and patient flow, and was used to inform the improvement plan.

There were robust governance arrangements in place within the emergency and urgent care service. Clinical audit was well-managed and used to drive service improvement. Risks were understood, regularly discussed and actions taken to mitigate them.

There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularly when the emergency department was under pressure. Here, staff felt respected, valued and supported. Morale was mostly positive, although to an extent was undermined by workload pressures. Service improvement was everybody’s responsibility. Staff were encouraged and supported to undertake service improvement projects.

The leadership and culture of the specialist palliative care team in the trust reflected the vision and values of the trust. Leadership encouraged openness and transparency and promoted good quality care. There were leads on the wards for delivery of end of life care which supported the development of high quality end of life care.

The trust had a clear vision and strategy to deliver care at end of life linked to national best practice including Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s.

The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.

Staff felt respected and valued. There was a strong emphasis on promoting the safety and wellbeing of staff delivering end of life care in the community.

Services within specialist palliative and end of life care had been continuously improved and sustainability supported since the last inspection March 2015.

However:

Safety concerns which we identified at our last inspection had not been addressed, despite the introduction of new processes. Patient flow remained the major barrier to progress. The emergency department’s management team did not feel there was a culture of collective responsibility within the trust in relation to patient flow. There was frustration expressed that the emergency department bore a disproportionate level of risk, while the responsibility for the exit block sat with others. The emergency department was unable to influence the cultural shift which was required to address this significant barrier to improving patient flow and capacity.

Pressures faced by staff in the emergency department in relation to crowding were well understood and articulated by the management team but it did not appear that the risks relating to staff wellbeing, resilience and sustainability, had been widely shared or escalated within the organisation and they were not included on the department’s risk register.

There was a limited approach to obtaining the views of people who used the service. Workload pressures prevented opportunities for staff reflection or meaningful staff engagement and involvement in shaping the service.

There was no risk register specific to end of life care for the trust so there was no easy trust wide oversight of risk relating to the service.

There was a program of internal and national audits for end of life care, which were on time. However most local audit activity had not yet benefited from a thorough analysis of the data produced.

Within the medical service there was a lack of overview and governance around mortality and morbidity (M&M) meetings. Risks registered on the risk register were not always aligned with risks in the service.

There was a lack of understanding of the risk to safe patient care, the acuity of patients have on daily basis.

We saw several areas of outstanding practice including:

The diagnostic imaging department sent radiographers onto wards to liaise with staff to identify inpatients that were waiting for scans, in order to help speed up treatment and ultimately discharge.

The therapies department had placed occupational therapists and physiotherapists on wards over Christmas to support and speed up patient discharges during a period of high pressure.

The inpatient specialist palliative care team had won an annual staff award the trust - patient’s choice award 2016. This was from patients and others who recognised the NHS staff who had made a difference to their lives.

The consultant in the end of life care team was part of a multi-disciplinary team who had won the national Linda McEnhill award 2016. The award was recognition by the Palliative Care of People with Learning Disabilities professional network of excellence in end of life care for individuals with learning disabilities. Work included improving how different teams worked better together.

The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Review processes to monitor the acuity of patients to ensure safe staffing levels.

Ensure wards are compliant with legislation regarding the Control of Substances Hazardous to Health (COSSH).

Improve record keeping so that patients’ records provide a contemporaneous account of assessment, care and treatment.

Ensure patients in the emergency department receive prompt and regular observations and that early warning scores are calculated, recorded and acted upon.

Ensure the mental health assessment room in the emergency department meets safety standards recommended by the Royal College of Psychiatrists.

When using the day surgery unit for inpatients, provision must be made for the cleaning of the units at weekends and to provide patients with clean water jugs and drinks.

Ensure emergency resuscitation trolleys are checked and have guidelines attached according to best practice guidance and in line with trust policy.

Ensure the safe management of medicines at all times, including storage, use and disposal and the checking and signed for controlled drugs. Ensure all drug storage refrigerator temperatures are checked and the results recorded daily. Additionally if the temperatures fall outside of the accepted range action is taken and that action recorded.

Ensure patient group directives are up to date and consistent in their information.

Ensure women attending the triage unit within the maternity service are seen within 15 minutes of arrival.

In addition the trust should:

Ensure all staff are compliant with efficient decontamination of hands on entering wards.

The medical service should collect information about mortality and morbidity (M&M) meetings electronically across all services to ensure an audit trail is maintained and outputs governed.

Ensure emergency equipment (including resuscitation trolleys) is checked daily in line with trust policy and national guidance.

Review processes to recognise and respond to blank boxes on prescription charts to make sure patients receive medicines as prescribed.

Review the process to assess risks to patients and ensure a management plan is in place.

Review process to comply with VTE assessment in line with trust policy and national guidelines.

Ensure treatment pathways are reviewed and update to ensure best evidence-based treatment.

Ensure all staff receive yearly appraisals in line with trust policy.

Review process to ensure patients are reviewed by a consultant within 14 hours of admission in line with the London Quality Standards (2013).

Review processes to ensure compliance with the accessible information standards.

Ensure areas used to admit patients in times of high organisational pressures are suitable and staffed to ensure safe care and treatment of patients.

Ensure effective monitoring of clinical improvement and audits, including compliance with accurate and timely NEWS assessments.

Ensure timely response to complaints in line with trust policy.

Ensure there are sufficient numbers of staff with appropriate skills and experience on each shift in diagnostic imaging.

Ensure identification procedures in diagnostic imaging are robust and recorded.

Ensure all staff are up to date with mandatory training.

Ensure all patient’s referral to treatment times do not exceed national targets including cancer wait targets.

Ensure steps are taken to reduce the current reporting backlog.

Ensure diagnostic imaging examinations are reported within target for the accident and emergency department.

Ensure steps are taken to monitor and reduce the numbers of temporary notes in use.

Ensure all hazardous chemicals and cleaning products are securely stored.

Review facilities for staff to take breaks and make drinks away from clinical areas

Ensure staff can effectively trace patient records through the hospital.

Ensure disabled toilets have sufficient alarm systems.

Ensure all risk identified relating to the provision of end of life care is included on a risk register.

Ensure the training needs analysis for general staff on wards related to end of life care is completed by the trust end of life care quality group

Consider involving specialist palliative care team and support teams in major incident plan practices or exercises.

Review the signage and consider if the system of using ‘white rose’ symbols to assist location of trust mortuaries is effective

Ensure specialist palliative care team are able to use the results of the safety thermometer information in relation to patients receiving end of life care.

Continue to work in collaboration with partners and stakeholders in its catchment area to improve patient flow within the whole system, thereby taking pressure off the emergency department, reducing crowding and the length of time patients spend in the department.

Ensure the emergency department is supported by the wider hospital and that there is more engagement from specialties in addressing the risks associated with patient flow.

Ensure the workload pressures and impact on staff wellbeing, associated with crowding in the emergency department, are understood, identified on the risk register and that staff are supported as appropriate.

Ensure all staff within the specialities is aware of Never Events and the learning needed to prevent a reoccurrence.

Continue to make improvements with the reduction of surgical site infection rates.

Review the pre admission clinic area for comfort and suitability

Provide resuscitation equipment for the pre admission unit to ensure if a patient collapsed, they receive the correct care in a timely manner.

Review the equipment in the pre-admission unit to ensure it meets the needs of the service.

Patient group directions (PGDs) should be reviewed as they were out of date and the correct authorisation signatures should be included.

Continue to work on your action plan to address the shortfalls identified in the mortality outliers.

Review the lack of 24-hour emergency theatre to ensure no patients will be put at risk.

Continue to address issues resulting from the new computer system.

Improve the number of staff appraisals completed.

Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.

Ensure emergency trolleys on the neonatal and children’s units have a system that easily highlights if an emergency trolley has been tampered with between routine checks.

Support all children’s services to contribute to infection prevention and control audits so that risk can be accurately assessed.

Consider options of protecting children’s safety when waiting for appointments in parts of the hospital that are not dedicated to paediatrics.

Continue with strategies to maintain staffing levels that meet national guidelines.

The trust should ensure electronic systems in place, especially for community midwives, enable them to input data in a timely way. Additionally they should have mobile phones with better connectivity to ensure they receive their messages in a timely way.

The trust should ensure that all inpatient venous thromboembolism (VTE) risk assessments are completed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Download full report

During a routine inspection

Gloucestershire Royal Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 683 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, services for children and young people, end of life care and outpatient and diagnostic imaging services. It provides specialist cancer care to patients from Gloucestershire, Worcestershire and Herefordshire as the hub for the three Counties’ Cancer Network

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new Intelligent Monitoring model. The inspection took place with an announced inspection 10–13 and an unannounced 20 March 2015.

Overall, Gloucestershire Royal Hospital was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Overall, critical care was rated as outstanding. Maternity and gynaecology and services for children and young people were rated as good with the remaining core services rated as requiring improvement.

The trust’s services are managed through a divisional structure that covers all the hospitals within the trust, with some staff rotating between the three sites of Gloucestershire Royal Hospital, Cheltenham General Hospital and Stroud Maternity Hospital; therefore there are significant similarities between the content of the three location reports.

Our key findings were as follows:

Safe

Safety was judged as good in critical care and surgery, but in all other areas it required improvement.

The emergency department was frequently overcrowded; this was associated with a lack of patient flow, which in turn led to the risk that patients might not be promptly assessed, diagnosed and treated. Patients were not always cared for in the appropriate part of the department, with particular concerns about the safety of patients being cared for in the corridor when the department was so busy that it could not accommodate patients in clinical areas.

Staff were aware of how to report incidents and felt encouraged to do so. However, overall the trust was reporting fewer incidents than the national average (6.8 per 100 admissions compared with 9.3 per 100 admissions for the NHS England average in the period from November 2013 to October 2014).

The majority to staff stated they received feedback after reporting incidents. In all areas there were examples of learning from incidents.

Overall, the hospital was visibly clean; however some areas, such as the room for patients with mental health needs and areas in the medical wards, were found to be dusty, dirty and, or to contain litter. We also found a number of hand gel dispensers that were empty.

The number of cases of Clostridium difficile was significantly lower than in previous years, and at 34 cases up to February 2015 was well below the trust’s target of a maximum of 55 for the year ending April 2015. There had been just one case of methicillin-resistant Staphylococcus aureus (MRSA) in the year to date.

Throughout the hospital we found medication stored in resuscitation trolleys was not secured to demonstrate it had not been tampered with between checks.

In some areas, records were not stored securely.

Review of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms showed that the forms did not consistently demonstrate or link to a reference of patients’ mental capacity, and this information was not obvious or easily accessible in other records. Explanations for the reason for the decision to withhold resuscitation were not always clear, and records of discussions with patients and their next of kin, or of reasons why decisions to withhold resuscitation were not discussed, were always not documented.

The majority of staff had attended safeguarding training in order to keep people safe from abuse. The exception to this was staff in urgent and emergency services, where for level 2 child protection training, particularly for junior doctors, completion rates were low, at 68% compared with the trust’s target of 90%.

Staff had access to a range of mandatory training, and attendance was monitored. Records showed that the majority of staff had attended the required mandatory training, and the trust’s target of 90% was exceeded. However, in the unscheduled care division, medical staff were performing less well at accessing such training.

Systems were in place to assess and respond to patient risk; these included risk assessments relevant to patients’ needs and early warning scoring systems to determine whether patients were at risk of deteriorating.

The trust’s target for completion of venous thromboembolism (VTE) risk assessment had not being met since the first quarter of 2013/14.

Nurse staffing levels had been reviewed and assessed, with oversees recruitment having taken place in order to meet the National Institute for Health and Care Excellence (NICE) Safe Staffing Guidance. Some areas, such as the flexible capacity wards, relied heavily on the use of bank and agency staff.

Medical staffing was at safe levels in many services. However, there were some exceptions; these included consultants in acute medicine, general and old age medicine and radiology, and junior doctors in medicine and emergency care.

The trust had a major incident and business continuity plan in place. The majority of staff were aware of their roles and responsibilities should the plan be activated.

Effective

Services were found to be effective in surgery, maternity and gynaecology, children and young people, end of life care and critical care. The latter we judged as outstanding. Improvements were required in urgent and emergency services and medicine.

In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.

Mortality rates were in line with those of other trusts, as measured by the Hospital Standardised Mortality Ratio.

Information about patient outcomes was routinely collected and monitored, with the trust participating in a number of national audits so it could benchmark its practice and performance against that of other trusts. In a number of these audits, the trust was performing less well than other trusts, for example the College of Emergency Medicine (CEM) audits, the National Sentinel Stroke Audits, The National Heart Failure Audit, and the Royal College of Physicians National Care of the Dying Audit 2104. Overall in surgery and critical care, the trust was performing better than the England average in most of the national audits it took part in.

Patient pain was assessed and well managed; the exception to this was in the emergency department, where not all patients had a pain score recorded and not all patients consistently received prompt pain relief.

In the ward areas, we found that patients had access to adequate food and fluids, observing that drinks were left within their reach.

Staff had access to training to develop their skills, knowledge and experience to deliver effective care and treatment. The trust’s target for the percentage of staff who had an annual appraisal was 90%, with the actual figure standing at 85%.

Multidisciplinary working was evident in all areas we inspected.

Overall patients were assessed in line with the Mental Capacity Act 2005 and care and treatment for patients unable to consent was undertaken in line with their best interest. However we did find one example where we were unable to find a documented assessment of a patient's capacity to make decisions despite evidence that this person was confused.

The hospital was working towards providing services seven days a week. The pharmacy service was open for limited hours on a Saturday and Sunday. Some on-call cover was provided at weekends by allied health care professionals. The palliative care team was available from 9am to 5pm Monday to Friday, with the specialist palliative care nurses providing an out-of-hours telephone advice service for clinicians.

Weekend ward rounds did not take place in some areas such as stroke, gastroenterology or the diabetes and endocrinology wards. In cardiology, a ward round took place on both days of the weekend.

Weekend discharges were problematic, with significantly fewer patients being discharged at this time.

Caring

Staff were providing kind and compassionate care with dignity and respect. Caring in critical care was outstanding, with all other areas rated as good.

In some areas such as the surgical admissions unit and outpatients, at times privacy could be compromised when personal conversations could be overheard and procedures seen.

Prior to the inspection we received a number of concerns from patients and relatives about a lack of clear communication; however, during the inspection we found that patients and, when appropriate, those close to them, were involved in decisions about patients’ care and treatment.

Patients generally received the support they needed to help them cope emotionally with their care, treatment and condition.

Spiritual support was available from within the hospital through the chaplaincy service, which provided a 24-hour on-call service.

Responsive

Urgent and emergency care and medicine required improvement; all other services were rated as good.

Bed occupancy at Gloucestershire Royal Hospital was constantly over 91%, which was above both the England average of 88% and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital. The hospital had been operating at near 100% occupancy in the months leading up to the inspection.

There were issues with the flow of patients into, through and out of the hospital. The emergency department frequently became overcrowded when demand for services exceeded capacity. This was a hospital- and community-wide issue. In December 2014 and January 2015, the trust had declared an internal major incident when the situation became unmanageable.

The standard that requires 95% of patients to be discharged, admitted or transferred with four hours of arrival in A&E was consistently not being met. Trust wide performance was 82.86% with Gloucestershire Royal Hospital achieving 80.59%.

There were numerous examples of initiatives to reduce inappropriate emergency department attendances, to ensure patients were directed to the appropriate services to prevent admission and to shorten length of stay. Some of these were in their infancy and not yet fully developed to enable an effective and comprehensive service to be provided seven days a week.

The average length of stay for patients admitted as elective cases fell to its lowest level in February 2015; however this masked a performance that was better than the national average in surgery and worse than the national average in medicine. For non-elective patients, the average length of stay had risen to 6.7 days, which was above the trust’s target of 5.8 days for the third month in a row.

The number of emergency admissions within 30 days of discharge for both elective and emergency patients was above the trust’s target and had been for the last year.

The 18-week referral to treatment targets were being met in almost all surgical specialities. Urology and ophthalmology were just behind the 90% target at 85% and 87% respectively. The trust was below (that is worse than) the NHS England average 62-day cancer waiting time target.

The number of elective patients cancelled on the day of admission for a non-medical reason had not met the target in over a year, reaching its peak over the three months from December 2014 to February 2015, which matched the time during which the trust had been facing significant increased demand. This was also reflected in the number of patients who were cancelled and not rebooked within 28 days, which saw a significant rise in January 2015.

There was an agreement with partners in the local health economy that the daily number of patients who were medically fit for discharge would not be more than 35 a day; this number had reached 74 in February 2015.

The two-week wait target for urgent GP referrals for cancer and the 62-day wait from GP referral to treatment were not consistently being met. However, other targets such as the 31 days for surgery and radiotherapy were constantly met, as was the 31-day period from diagnosis to treatment.

Systems were in place to identify patients who were living with dementia or who had a learning disability and might need additional support.

Patients knew how to make a complaint if they wanted to, and information was available around the hospital outlining how to make a complaint and how it would be dealt with. There were examples of learning from complaints to improve care.

Well led

Leadership in critical care was rated as outstanding; surgery, maternity and gynaecology, children and young people, and outpatients were also well-led. Urgent and emergency care, medicine and end of life care all required improvement.

Most services had a five-year strategy in place. The exception to this was end of life care. Whilst the team demonstrated understanding of the national policy and priorities, there were no defined work plan priorities for Gloucestershire Royal Hospital for the present and future.

Staff were generally aware of the trust’s values of listening, helping, excelling, improving and uniting.

The trust was organised into four clinical divisions which operated across all trust sites; each was led by a chief of service, a divisional nursing director and a divisional operations director. This team was supported by a clinical director, a matron and a general manager in each specialty. Staff in all areas stated they felt supported by these lead staff. Of the executive directors, the director of nursing was singled out by many staff as visible and approachable.

Generally appropriate governance systems were in place; each specialty had governance meetings, and these were reported to the divisional governance meetings, with significant issues reported on to the trust’s quality governance meetings. Shortcomings were identified in two main areas. Monitoring of mortality and morbidity meetings in medicine was poor. We were informed these meetings took place, but we were not able to view any minutes of these meetings. In end of life care, governance and quality measurement were inconsistent. Whilst governance meetings were held, the minutes lacked details on information relating to actions planned or taken.

In the 2014 staff survey, the trust was performing less well than other trusts on staff engagement; however, there had been an improvement from the previous year. Many staff told us about the executive walk-arounds and the top 100 leaders’ information meetings.

We saw several areas of outstanding practice including:

Patients living with dementia on Ward 9b were able to take part in an activity group, which had been organised by one of the healthcare assistants. The activity group enabled the patients to become involved in activities and encouraged them to maintain their skills and independence. The group was held weekly, and patients were able to play bingo, watch films, take part in reminiscence, paint, sing and eat lunch together. Activities were tailored to individual preferences, and relatives were encouraged to be involved.

The trust had a mobile chemotherapy unit which enabled patients to receive chemotherapy treatment closer to their homes, to prevent frequent travel to hospital.

Patient record keeping in critical care was outstanding. All the patients’ records we saw were completed with high levels of detail. The records contained all the essential details to keep patients safe and ensure all staff working with them had the right information to provide safe care and treatment at all times.

There was an outstanding holistic and multidisciplinary approach to assessing and planning care in the department of critical care. All the staff involved with the patients worked with one another to ensure the care given to the patient followed an agreed treatment plan and team approach. Each aspect of the care and treatment had the patient at its centre.

In critical care, there was an outstanding commitment to education and training by both nurses and trainee doctors. Nurses and trainee doctors followed comprehensive induction programmes that were designed by experienced clinical staff over many years. All the staff we met who discussed their training and development spoke very highly of the programmes on offer and there being no barriers to continuous learning.

There was outstanding care for bereavement in critical care. All staff spoke highly of how they were enabled to care for and support patients and relatives at this time. Bereavement care had been created with input from patients, carers, relatives and friends, and staff were particularly proud of the positive impact it had on bereaved people and patients nearing or reaching the end of their life.

The outstanding arrangements for governance and performance management in critical care drove continuous improvement and reflected best practice. There was a serious commitment to leadership, governance and driving improvements through audits, reviews, and staff honesty and openness. All staff had a role to play in this area and understood and respected the importance of their work.

Mobility in labour was promoted with the Mums Up and Mobile (MUM) programme, which included wireless cardiotocography (CTG) monitoring across the whole of the delivery suite.

Importantly, the trust must:

Improve its performance in relation to the time patients spend in the emergency department to ensure that patients are assessed and treated within appropriate timescales.

Continue to take steps to ensure there are sufficient numbers of suitably qualified, skilled and experienced consultants and middle grade doctors to provide senior medical presence in the emergency department 24 hours a day, seven days a week, and to reduce reliance on locum medical staff.

Continue to reduce ambulance handover delays and take steps to ensure that patients arriving at the emergency department by ambulance do not have to queue in the corridor because there is no capacity to accommodate them in clinical areas.

Develop clear protocols with regard to the care of patients queuing in the corridor. This should include risk assessment and the identification of safe levels of staffing and competence of staff deployed to undertake this care.

Work with healthcare partners to ensure that patients with mental health needs who attend the emergency department out of hours receive prompt and effective support from appropriately trained mental health practitioners.

Take immediate steps to address infection control risks in the ambulatory emergency care unit.

Ensure that systems to safeguard children from abuse are strengthened by ensuring that children’s safeguarding assessments are consistently carried out, and safeguarding referral rates are audited to ensure they are appropriate.

Ensure that senior medical staff in the emergency department are trained in level 3 safeguarding.

Ensure that patients in the emergency department have an assessment of their pain and prompt pain relief administered when necessary.

Take steps to strengthen the audit process in the emergency department to provide assurance that best (evidence-based) practice is consistently followed and actions continually improve patient outcomes.

Ensure minutes are kept of mortality and morbidity meetings in medicine so that care is assessed and monitored appropriately, lessons learnt and actions taken and recorded.

Ensure that patients’ records across the hospital are stored securely to prevent unauthorised access.

Ensure that the premises for the medical day unit are suitable to protect patients’ privacy, dignity and safety.

Ensure an effective system is in place in the medical wards to detect and control the spread of healthcare-associated infection.

Ensure patients’ mental capacity is clearly documented in relation to ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) and ‘unwell/potentially deteriorating patient plan’ (UP) forms. Improvements in record keeping must include documented explanations of the reasoning behind decisions to withhold resuscitation, and documented discussions with patients and their next of kin, or reasons why decisions to withhold resuscitation were not discussed.

Ensure that where emergency equipment in the form of resuscitation trolleys is not available, the decision to not supply is based on a thorough risk assessment. Where emergency equipment is available, this should be ready to use at all times.

Review communication methods within maternity services to ensure sensitive and confidential information is appropriately stored and handled whilst being available to all appropriate staff providing care for the patient concerned.

Ensure that systems are in place to ensure that medication available in departments is in date and therefore safe to use.

In addition the trust should:

Review how staff perceive the feedback they get from incident reporting and the level of detail received.

Ensure that patients, including children, are adequately monitored in the emergency department waiting room to ensure that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

Take steps to improve the experience for patients and visitors in the emergency department waiting room. This should include the provision of drinking water, a TV, and appropriate reading material and information about waiting times.

Review the emergency department nursing staff mix and training to ensure adequate numbers of staff are trained to identify, care for and treat seriously ill children.

Continue to improve hospital-wide ownership of the emergency department four-hour target, to ensure that delays in admission are minimised.

Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.

Ensure all staff in surgery services are able to demonstrate and understanding of the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards, so patients are not put at unnecessary risk of staff not acting legally in their best interests. Ensure there is appropriate documentation in place to support decisions.

Ensure that the ambulatory emergency care unit is sited in an appropriately equipped area that is conducive to ensuring patients’ comfort and dignity.

Consider displaying feedback from patients and relatives for each individual medical ward.

Consider a system to identify when patient equipment has been cleaned.

Ensure all areas are clean and free from litter.

Store all medicines in critical care in a way that meets requirements for their security.

For safety of the medicines and equipment inside, ensure resuscitation trolleys are secured in such a way so there is clear evidence if they have been opened between checks.

Capture and report safety thermometer data in the department of critical care alongside the other data on patient harm that the department collects.

Ensure all items are within their expiry date.

Maintain continuity of care for patients on the day surgical unit to ensure they have their needs met 24 hours a day, seven days a week.

Review the medical and surgical cover at weekends for the day surgery unit to make sure patients are reviewed and discharges not held up.

Ensure patients who are admitted to the surgical day surgery unit can have their needs met by the staff team.

Reduce the number of times patients are moved between wards, for continuity of care.

Review the staffing levels of physiotherapists against the requirements of the Faculty of Intensive Care Medicine Core Standards.

Ensure the specialist palliative care team can be sustained and are able to remain responsive to the evidenced increased demands of complex referrals, provide a face-to-face seven-day service, provide ongoing staff training in line with national policy, and make improvements to inconsistent governance, risk management and quality measures.

Ensure that a strategy for end of life care is developed.

Ensure all patients who are referred by their GP with suspected cancer are seen with two weeks of referral, and treatment is started within 62 days of referral.

Ensure the cleaning arrangements for all outpatient areas are appropriate to maintain a high standard at all times.

Ensure that where medication is required to be stored at refrigeration temperatures, systems are in place to monitor the correct temperature.

Ensure that systems are in place in outpatients to identify in a timely manner and replace medication that is approaching its expiry date, to prevent potential harm to patients.

Ensure patients’ privacy and dignity is consistently respected in the outpatient department and medical unit.

Ensure patients in outpatients have access to information on the trust’s complaints procedure, and that this is readily available in all areas.

Ensure staffing levels and the skill mix of staff in the diagnostic and imaging teams meet the needs of patients at all times and support staff to deliver a quality service.

Review, in the maternity services, the midwifery and support staffing to ensure there are sufficient staff to meet patients’ needs at all times in all areas.

Ensure that in maternity services, both service risk registers detail actions underway to mitigate risks.

Review cleaning schedules in maternity services and devise systems to ensure staff know when equipment has been cleaned and is ready for use.

Within maternity services, review the provision of oxygen and air on resuscitaires to ensure that the correct gases are administered during resuscitation, in line with the Resuscitation Council guidelines.

Review the location of the maternity services’ registrar clinic and early pregnancy assessment clinic (at weekends) to ensure facilities are appropriate to provide care, assessment and treatment.

Review the processes to ensure early screening (pre 10 weeks’ gestation) can occur where the need for such screening is indicated.

Within maternity services, work with the wider organisation to ensure overall patient flow is effective to prevent the need for cancellation of gynaecology patients because of the need to accommodate other patients on Ward 2a.

Review the timeliness of access to patient information in alternative languages.

Ensure staff in all areas of maternity services are aware of the procedures to follow in the event of early discharge ahead of the completion of all bereavement processes.

Ensure all patients’ referral-to-treatment times do not exceed national targets, and that services are delivered in a way that focuses on patients’ holistic needs and does not mean patients experience long delays in receiving their first outpatient appointment.

Professor Sir Mike Richards, Chief Inspector of Hospitals

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During a routine inspection

We carried out this inspection of the neonatal and paediatric services at Gloucester and Cheltenham hospitals in response to a request from the coroner’s office. The coroner made this request because they had concerns about the service provided in both hospitals after the death of a baby at Cheltenham hospital in December 2010. We were asked to check if current arrangements at these hospitals were putting babies at risk.

We found that in 2011 the trust had re-structured the maternity services and all the neonatal and paediatric services had been moved to the Gloucester site. Cheltenham hospital now had a midwife led birthing centre for low risk births. During this inspection we visited the neonatal and paediatric units in Gloucester and the birthing centre in Cheltenham. We spoke with ten staff and five parents of babies who were being cared for in the units.

All parents we spoke with were very positive about their experience of the service. All staff we spoke with told us they felt supported to carry out their roles had had access to relevant training. There was evidence that learning from incidents took place and appropriate changes were implemented. Records were accurate and fit for purpose.

Overall we found that people who used the neonatal and paediatric services at Gloucester and Cheltenham hospitals received good care. We found no evidence to suggest that babies born in any of the units across both hospitals were being put at risk.

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During a routine inspection

During our visit to Gloucester Royal Hospital we spent time on two General and Old Age Medicine (GOAM) wards and the discharge waiting area. We also looked at documentation for patients who were being discharged from four other wards. We spoke with 25 patients, four relatives and eight staff as well as observing staff interaction with patients.

We observed patients being treated with dignity and respect. Staff addressed patients by the name of their choice and we observed staff joking and laughing with patients in a friendly and respectful manner. Patients we spoke with told us staff treated them well. Patients told us “I just can’t fault it, they’re ever so nice to me, it’s like a little family, you get to know them and they get to know us” and “It’s better than a hotel in here, they can’t do enough for you”.

All patients we spoke with told us they enjoyed the food. They told us “I’ve had some excellent meals while I’ve been in here. I only tick the ones I like but they’ve been lovely” and “The food just gets better and better….”

We spoke with eight patients who were being discharged during the two days of our visit. Patients we spoke with who were being discharged spoke positively about how they had been informed of their discharge arrangements. One patient who was being discharged to a community hospital told us “It’s been very good here, everyone’s really looked after me and they have arranged everything for me. I just have to wait for the ambulance”.

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During an inspection to make sure that the improvements required had been made

People that we spoke to were pleased with the treatment they had received. We received comments such as, "I have had excellent care", "I am being well looked after" and "I am being cared for very well". One person told us "I can get hold of a daily paper. A nurse will go or a bloke came round yesterday", and another said "a gentleman comes round to offer to get things from the shop. He got me some tissues and some bottled water yesterday".

People that we spoke to were positive about the food at the hospital. People made comments such as "The food is very good, I wouldn't fault it", "The food is ok, I have really enjoyed some meals" and "I have put on weight, I would like smaller meals".

People that we spoke to were pleased with the cleanliness of the hospital and told us "I cannot fault them for cleanliness", and "It is very clean. They clean every day". One person told us "I was pleasantly surprised by how clean it was".

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During an inspection in response to concerns

People told us that were pleased with the staff that had treated them. One said, ‘The staff are brilliant, excellent, really nice,’ Another said, ‘Staff are lovely and helpful, they put themselves out for you, and another said, ‘They are kind on this ward and sit with patients as long as it takes’. One person told us ‘They don’t let you go home until you can cope’.

A number of people told us how busy the staff were with comments like, ‘The staff are excellent. They are so busy; they don’t always come when you call them,’ ‘The staff are alright. They are trying to do too many jobs at the same time,’ and, ‘Staff are lovely. They are very nice. They have a difficult job.’

Some people, particularly those who had been in the hospital for longer periods of time, told us that they were very bored, with little daytime activity. One person said, ‘There’s not much to do. I can’t see the television and there are no papers,’ and another said, ‘There is no longer a newspaper trolley’. One person we spoke to said, ‘I can’t see a clock, so I don’t know what time it is’

People were particularly positive about the food at the hospital, and we received comments such as, ‘The food is good, they are big portions for me and I feel full up,’ ‘The food is excellent. When I came in I was not well enough to eat and now I am eating,’ and ‘I have put on weight in a week’. Another person said ‘There is plenty to eat and drink’. One person told us that the food at the hospital has improved recently, saying, ‘I was here six months ago and the food is better.’ Some people had more mixed feelings and one said, ‘The food is okay. You can’t please everyone’, while another told us ‘I would not give it a star, perhaps half a star. I like plain meat and two veg so I have the same food every day, casserole. I don’t like newer stuff like pasta.’

A number of people remarked on the cleanliness of the hospital. People gave us comments such as ‘They are constantly cleaning here’, ‘The cleanliness is excellent; they move the beds to clean under them’, and ‘The cleanliness is excellent, really good. The curtains are cleaned and changed’

One person said ‘It’s been nice to meet you and be able to tell someone how good the place is’.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.